Unraveling the link between hypertriglyceridemia, dampness syndrome, and chronic diseases: A comprehensive observational study

To investigate the dampness syndrome score in hypertriglyceridemia and the correlations between hypertriglyceridemia and other chronic diseases and lifestyle factors. Data were retrospectively obtained from individuals who underwent physical examinations at Guangzhou Cadres Health Management Centre from May 2022 to May 2023. t Test, variance analysis, and chi-square test were used to compare the score of dampness syndrome and the prevalence of hypertriglyceridemia among different subgroups. Pearson, Spearman correlation analysis, and regression analysis were used to explore the correlations between hypertriglyceridemia and dampness syndrome, chronic diseases, and lifestyle factors. The prevalence of hypertriglyceridemia was 26.70%. Clinical test index and dampness syndrome score were significant differences between hypertriglyceridemia group and normal group (P < .05). Subgroup analyses as a function of the degree of triglyceridemia indicated that the dampness syndrome score increased with increasing degree of triglyceridemia (P < .05). Correlation analysis showed that hypertriglyceridemia was correlated with dampness syndrome, overweight/obesity, hypertension, diabetes, and other chronic diseases (P < .05). Multivariate logistic regression analysis showed that age, sex, marriage, education level, smoking, drinking, fruit consumption, vegetable consumption, milk and dairy product consumption, dessert or snack consumption, the degree of dampness syndrome, and engagement in exercise were associated with hypertriglyceridemia (P < .05). Hypertriglyceridemia is associated with a variety of chronic diseases and lifestyle factors, and is closely related to dampness syndrome. The score of dampness syndrome can reflect hypertriglyceridemia to a certain extent. It provides more clinical reference for the treatment of hypertriglyceridemia combined with the analysis of dampness syndrome of traditional Chinese medicine.


Introduction
Hypertriglyceridemia is a common type of dyslipidemia and a risk factor for a variety of diseases, including atherosclerotic cardiovascular disease and acute pancreatitis. [1,2]A Korean cohort study suggested that the triglyceride (TG) level is an independent predictor of cardiovascular events in young adults (20-39 years) who have not taken statins; the risk of cardiovascular events was increased by 20% with TG levels in the highest quartile. [3]Previous studies have shown that residual The study was funded by the State Key Laboratory of Dampness Syndrome of Chinese Medicine Open Project, No. JGZX-2023-06.
An informed consent was obtained from all participants included in the study.

The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.
cardiovascular risk persists even when low-density lipoprotein cholesterol (LDL-C) is reduced to the recommended target, and this residual risk may be attributed to atherosclerotic dyslipidemia, including elevated TGs. [4]Previous studies have also demonstrated a positive correlation between elevated TG levels and increased risk of cardiovascular disease and mortality. [5,6]This association is endorsed by the American Heart Association. [4]ithin traditional Chinese medicine (TCM) theory, "dampness syndrome" refers to a category of symptoms caused by dampness invading the muscles, meridians, bones and joints, paralyzing and blocking "qi" and blood flow, or internal viscera stagnation of "qi", [7,8] in which the human body is in a state of disease.The occurrence of dampness syndrome may be closely related to the geographical environment, body dysfunction, and abnormal body fluid metabolism. [9,10]According to TCM theory, dyslipidemia has certain similarities with the expressions of "blood turbidity" "cream fat" and "fat man", and such diseases are mostly attributed to dampness.Zhang et al [11] analyzed 196 patients with dyslipidemia in Guizhou Province and found that damp heat and phlegm-dampness were evident in the highest proportions of these patients, suggesting that they may act as risk factors for dyslipidemia.Zhang and Lu [12] found that the TG level of patients with phlegm-dampness hyperlipidemia was higher than that of other groups.Together, these findings suggest that dampness syndrome may also be a risk factor for hypertriglyceridemia (HTG)."Preventing diseases before they occur" and "three-cause approach" are the essence of Chinese medicine in preventing and treating diseases.In order to construct the treatment strategy of HTG in the field of TCM, it is crucial to explore the relationship and distribution characteristics of dampness syndrome with HTG and chronic diseases.Thus, it is worth studying whether the "dampness" characteristic of the human body can serve as an intuitive, noninvasive, low-cost, and timely indicator of abnormal blood lipids.Systematic studies on the relationship between dampness syndrome of TCM, HTG, and chronic diseases are still rare so far.This study may provide an important reference basis for the study of the relationship between the three.To this end, this study aimed to characterize dampness syndrome in the HTG population, analyze the lifestyle risk factors for HTG, and examine the correlations between HTG, dampness syndrome, and chronic diseases.The ultimate goal was to provide health guidance for the HTG population and data to support interventions and treatments for HTG.

Subjects
Data were retrospectively obtained from public officials who underwent physical examinations and completed the TCM dampness syndrome evaluation scale at Guangzhou Cadres Health Management Centre from May 2022 to May 2023.A total of 7701 individuals with complete data were included in the analyses.The sample ranged in age from 22 to 75 years, with an average age of 44.88 ± 11.55 years.This study was approved by the Ethics Committee of Guangzhou Cadre Health Management Centre.All participants provided written informed consent.

Diagnostic criteria
The diagnostic criteria for HTG were as follows [13] : based on the fasting TG level, TGs were classified as marginal elevation (≥1.7 and <2.3 mmol/L), mild to moderate elevation (≥2.3 and <5.6 mmol/L), or severe elevation (≥5.6 mmol/L).The degree of dampness syndrome [14] was evaluated according to the Diagnostic Evaluation Scale of TCM Dampness Syndrome issued by the State Key Laboratory of Dampness Syndrome of Chinese Medicine.The scale is a self-rating scale for patients with 30 items, and each item is classified into 5 grades according to the degree of zero, mild, moderate, severe, and extremely severe, which are 0, 1, 2, 3, and 4 points respectively, shown in Table S1, Supplemental Digital Content, http://links.lww.com/MD/N349.The maximum score on the scale is 120 points; the higher the score, the more serious the degree of dampness syndrome.Scores of 0-19 points are classified as "no dampness syndrome"; 20-39 points are classified as "mild dampness syndrome"; 40-59 points are classified as "moderate dampness syndrome"; 60-79 points are classified as "severe dampness syndrome"; ≥80 points are classified as "extremely severe dampness syndrome."

Inclusion and exclusion criteria
The inclusion criteria were as follows: completed the TCM Dampness Syndrome Evaluation Scale and obtained a score ≥0;  was able to provide written informed consent, cooperate with the completion of the questionnaire and provide a blood sample; aged ≥20 years old and ≤75 years old.The exclusion criteria were as follows: cannot cooperate with the project; patients with mental illness; pregnant or lactating women; patients with serious primary heart, liver, kidney, and other diseases of key organs.

Methods
Participants completed a survey, physical examination, and laboratory blood tests.All data were extracted from the physical examination system of the health management center.We randomly selected participants among those who came for medical checkups and arranged for trained investigators to assist in questionnaire completion to ensure the completeness and authenticity of data collection to minimize bias.During the data analysis of this study, there were no missing data except for insufficient response.

Statistical methods
SPSS 26.0 statistical software was used for the statistical analysis of the data.The measurement data were expressed as the mean ± standard deviation (χ ± s).t Tests, variance analysis, and chi-square tests were used for comparisons between groups.
Pearson correlation analysis was used for normally distributed variables and Spearman correlation analysis was used for nonnormally distributed variables.Count data were compared by chi-square tests.The factors influencing HTG were analyzed by binary logistic regression analysis.P < .05 was considered statistically significant.

Comparison of the physical examination indices between the HTG group and normal group
The differences between the 2 groups are shown in Table 1.
The mean age, waist circumference, BMI, SBP, DBP, BUA, serum creatinine, blood urea nitrogen, FBG, TG, LDL-C, alanine aminotransferase, aspartate aminotransferase, glutamyl transpeptidase and dampness syndrome score in the HTG group were higher than those in the normal group.The high-density lipoprotein cholesterol level was lower in the HTG group than in the normal group (P < .05).There was no significant difference in the mean heart rate between the 2 groups (P = .514).

Comparison of dampness syndrome scores in people with triglyceridemia
The dampness syndrome scores of the sample as a function of the level of triglyceridemia are shown in Table 2.The dampness syndrome scores increased with increasing degree of triglyceridemia (P < .05).However, there was no significant increase in the severely elevated group compared with the mild-moderate elevated group.

Comparison of dampness syndrome scores in different age groups
As shown in Table 3, the dampness syndrome scores in people between 20 and 40 years old increased with age, while the scores of dampness syndrome in people over 40 years old decreased with age, and the difference between age groups was statistically significant (F = 36.74,P ≤ 0.001).

Comparison of HTG among different demographic characteristics
As shown in Table 4, there were significant differences in the prevalence of HTG between different genders, marital status, and educational level (P < .001).

Comparison of TG levels as a function of the degree of dampness syndrome
The comparison of the TG levels as a function of the degree of dampness syndrome is shown in Table 5.With the exception of the extremely severe dampness syndrome group, the greater the degree of dampness syndrome, the higher the serum TG content; this relationship was statistically significant (P < .05).Gender stratification was then performed and the trend in the TG level in the male group was consistent with the overall trend, while the mean TG level in the females with severe dampness syndrome and above showed a downward trend (P < .05).

Correlations between HTG, dampness syndrome, and chronic diseases
The correlations between HTG, dampness syndrome, and chronic diseases are shown in Table 6.Hypertriglyceridemia was significantly correlated with dampness syndrome, overweight/obesity, hypertension, diabetes, coronary atherosclerosis, carotid plaques, emphysema, thyroid nodules, and hyperuricemia (P < .05).According to gender stratification, the correlations between HTG, chronic diseases, and dampness syndrome was different in different genders.

Correlations between HTG, demographic characteristics, and lifestyle factors
A description of the variables included in this analysis is provided in Table 7.The correlations between HTG, demographic characteristics, and lifestyle factors are shown in Table 8.Hypertriglyceridemia was significantly correlated with gender, age, marital status, education level, length of air conditioning in summer, smoking, frequency of drinking, frequency of night snack intake, structure of staple food consumption, frequency of fruit intake, frequency of milk/beans and milk/bean product intake, frequency of dessert or snack intake, daily time sitting, midday rest time, daily sleep duration and degree of TCM dampness syndrome(P < .05).

Binary logistic regression analysis of HTG and related indicators
The regression analysis of HTG and related indicators is shown in Table 9 and Figure 1.Binary logistic regression analysis was performed with HTG as the dependent variable and indicators such as dampness syndrome and lifestyle factors as the independent variables.The results revealed that age, sex, marriage, education level, frequency of smoking, frequency of drinking, frequency of fruit intake, daily intake of vegetables, frequency of milk and milk product intake, frequency of sweets intake, degree of TCM dampness syndrome and exercise were predictors of HTG (P < .05).

Discussion
Dyslipidemia has become increasingly common among Chinese adults in recent years due to improvements in living conditions. [15]HTG is a type of dyslipidemia.A study of adults in Wuhan, China, in 2019 reported that the prevalence of HTG was 13.9% (19.8% in men and 5.8% in women). [16]In 2021, a health survey of 4598 adult residents in Shanxi Province found that the incidence of HTG reached 33.3%. [17]In the current study, the prevalence of HTG was 26.7%.An elevated TG concentration has repeatedly been found to be a strong independent risk factor for cardiovascular disease [18,19] and an important independent predictor of all-cause mortality for all races. [20,21]herefore, early identification of HTG is crucial for the prevention of cardiovascular disease and the reduction of all-cause mortality.TCM classifies substances such as TGs and BUA as "water and grain subtle," and if they are not normalized, they will release harmful substances into the body. [22]Epidemiological studies of the physical constitution have indicated that phlegm dampness and damp-heat constitution are closely related to metabolic disorders such as diabetes and hyperlipidemia. [23,24]he study by Huang et al [25] suggested that in phlegm-dampness, there is a reduction in the ability to clear blood lipids and regulate lipid metabolism, and thus, the phlegm-damp population is more likely to suffer from HTG. [26] Previous studies paid more attention to the relationship between different constitutions and metabolic disorders in TCM, and rarely explored the relationship between dampness syndrome and HTG.In addition to focusing on the relationship between dampness syndrome and Description of the demographic variables and lifestyle factors.metabolism, this study further quantified the dampness syndrome score to explore the relationship between different degrees of dampness syndrome, HTG, and chronic diseases.The current study revealed that the average dampness syndrome score of the HTG group was higher than that of the normal group, and the dampness syndrome score increased with increasing degree of triglyceridemia (P < .05);although, the severely elevated group did not show an obvious increasing trend.Similarly, serum TG levels increased with increasing degree of dampness syndrome (P < .05).Moreover, regression analysis showed that the degree of TCM dampness syndrome was positively correlated with HTG and was an independent predictor of HTG, suggesting  that the TCM dampness syndrome score could reflect the state of triglyceridemia to a certain extent.However, the TG content in the extremely severe dampness syndrome group did not show an increasing trend.This may be related to the small number of people in this group (only 27 cases).Further studies with larger sample sizes are needed to clarify the relationship between extremely severe dampness syndrome and TGs.The current study also found that metabolic indicators such as BMI, SBP, DBP, FBG, and BUA were higher in the HTG group as compared to the normal group.Further analysis of the correlations between HTG and chronic diseases revealed that HTG was correlated with multiple chronic diseases such as overweight/obesity, hypertension, diabetes, and carotid plaques.This is consistent with previous reports.A study of Sri Lankan adults reported a positive correlation between serum TG levels and BMI. [27]Peng et al [28] reported that high TGs were significantly correlated with hyperuricemia.A prospective cohort study [29] found that high TGs increased the incidence of hyperuricemia.Pan et al [30] showed that up to 50% of overweight and obese people have HTG.Wyszyńska et al [31] found that HTG is an independent risk factor for hypertension.Other studies have shown that in patients with type 2 diabetes, the main abnormality of lipid metabolism is a high TG level. [32]In a recent study investigating, the association between dyslipidemia and diabetes, fasting TG levels were identified as an independent risk factor for the onset of diabetes (odds ratio: 2.33, 95% confidence interval: 1.61-3.39). [33]Whether dampness syndrome is a risk factor for HTG and other diseases requires investigation in a future prospective study.

Sex
The results of the current study indicated that age, gender, marriage, education level, smoking, drinking, fruit consumption, vegetable consumption, milk and milk product consumption, sweets consumption, degree of TCM dampness syndrome, and exercise are predictors of HTG.[36][37] For example, Spitler and Davies [34] found that age-induced changes in human TG metabolism include an increased plasma TG level, decreased plasma TG clearance after meals, decreased lipolysis in adipose tissue, and increased ectopic fat deposition.In another study, an additional 100 g of ethanol intake per week increased serum TG by 0.041 mmol/L. [38] cross-sectional study of obese adults in Malaysia found that elevated TG levels were more prevalent in men, married people, and smokers. [39]Vegetable intake has been found to be negatively correlated with increases in TG, [40] and daily physical exercise has been found to effectively reduce the TG level. [41]n short, a poor lifestyle can increase the TG level.Thus, HTG patients should maintain a healthy lifestyle to reduce their TG levels.
Increasing evidence from studies has shown that HTG has adverse effects on health, and rational and rapid medication intervention is necessary to delay the progression of related diseases.As an important part of Chinese traditional medicine, TCM has a long history and rich clinical experience, especially in chronic diseases, subhealth states, and individualized medical treatment.With the increasing demand for health and medical care, the research on the combination of clinical medicine and TCM has a broad application prospect and important social significance, which has a certain guiding significance for the clinical medication judgment of HTG.Countless clinical practices have proved that TCM does have efficacy, [42,43] and exploring the relationship between TCM evidence and disease development, finding out the scientific nature of TCM dialectics and its biological basis can provide a basis for the foundation of modern medicine in TCM.
There are several strengths of this study that should be highlighted.First, to our knowledge, this is the largest populationbased study of the association between HTG and dampness syndrome.This study found, for the first time, that the dampness syndrome score can reflect the state of HTG to a certain extent, and thus, quantifying "dampness" in TCM may offer an intuitive and noninvasive means to assess the TG level.However, this study also has some limitations that should be considered.First, this was a single-center cross-sectional study.The results indicated that HTG is correlated with dampness syndrome and several chronic diseases; however, the causal relationships between these variables could not be determined.Any causal relationships need to be confirmed in future prospective studies.In addition, this study excluded participants with missing data, which could potentially result in selection bias.Subsequently, we will continue to explore the relationship and changes between TCM dampness syndrome and HTG using a multicenter, prospective cohort study.
In summary, this study revealed a correlation between the TCM dampness syndrome score and HTG.Thus, the dampness syndrome score can be used as an auxiliary indicator for predicting HTG, which is noninvasive and rapid in clinical application.The results of this study also confirmed that HTG is associated with a variety of chronic diseases and lifestyle factors.We will follow up the enrolled HTG population at different time points to dig out the changes of HTG, chronic diseases, and dampness syndrome score over time, and look for the trends and patterns of changes, so as to be used for health guidance.

Figure 1 .
Figure 1.Binary logistic regression analysis of hypertriglyceridemia and related indicators.

Table 1
Comparison of physical examination indices between the hypertriglyceridemia group and normal group.

Table 2
Comparison of the dampness syndrome scores as a function of the triglyceride level.

Table 3
Comparison of dampness syndrome scores in different age groups.

Table 4
Comparison of hypertriglyceridemia among different demographic characteristics.

Table 5
Comparison of triglycerides levels of the sample as a function of the degree of dampness syndrome.

Table 6
Correlations between hypertriglyceridemia, dampness syndrome, and chronic diseases.

Table 8
Correlations between hypertriglyceridemia, demographic characteristics, and lifestyle factors.

Table 9
Binary logistic regression analysis of hypertriglyceridemia and related indicators.